Cold, dry, windy winter weather can play havoc with our health but independent pharmacies are on hand to provide relief, as Steve Titmarsh explains…

One of the things people tend to suffer with as a result of winter is their lips, which become flaky and sometimes end up cracking. Infection with viruses or fungal species can lead to further problems such as cold sores and cheilitis.

Fortunately, there is a range of over-the-counter medicines and other products that pharmacists can offer to manage symptoms. And they can provide patients with advice on how to rid themselves of symptoms as quickly as possible as well as trying to prevent or limit the impact of further episodes.

Infections with herpes simplex virus are usually mild and self-limiting. The virus can infect the lips, cheeks or nose, when the condition is referred to medically as herpes labialis – more commonly known as cold sores. Herpes simplex virus type 1 causes 9 out of 10 cases of herpes labialis. Rarely, herpes simplex type 2 is the cause and it is often associated with orogenital sex.¹

Cold sores can recur – especially in the first six months after the first infection – because following the first infection the virus can move to the local sensory ganglia (often the trigeminal nerve ganglion) and stay dormant indefinitely. When it reactivates it can cause more symptoms or just shed virus with no clinical symptoms.¹

Cold sore treatment

Cold sores will generally clear up within a week to 10 days, even without treatment. Cold sore creams containing an antiviral such as acyclovir can help symptoms clear more quickly, especially if they are applied at the first sign of a cold sore developing such as a tingling, itching or burning sensation, when treatment may even prevent an outbreak altogether.²

Topical antiviral creams are available over the counter to relieve the symptoms of mild uncomplicated infection from herpes simplex that causes cold sores.³ A thin film of cream should be applied to the infected and immediately adjacent skin areas 5 times a day at 4-hour intervals during the day and continued for 4 days. If the cold sores do not heal treatment can continue for up to 10 days. If the cream has not worked in that time patients should be advised to see their GP.⁴

Unfortunately there is little evidence that topical antiviral medicines can prevent recurrence of cold sores, so avoidance of triggers, if known, is a good strategy.

Sometimes people will know what triggers their cold sores so avoiding or protecting against those triggers, for example by wearing sunscreen if sunlight causes cold sores to break out, may help prevent them altogether.⁵Minor injury and stress can also bring on another bout of cold sores.⁶

To stop a cold sore from spreading it is important to avoid touching it unless applying a topical medicine formulation, which should be dabbed on gently and not rubbed in. Hands should be washed after each application of cold sore cream or touching the area that is infected. Avoid sharing things like cutlery, and avoid kissing or oral sex until cold sores have cleared completely.⁵

People who experience pain can be advised to take paracetamol and / or ibuprofen if there are no contraindications to the drugs.¹ Some people find a topical anaesthetic helps relieve symptoms. Indeed, a small trial, found that lidocaine 5% ointment prevented outbreaks in 1 in 3 of the participants and shortened the outbreaks that did occur from 5 days to 2 days.⁷

To help cold sores clear patches containing hydrocolloid gel can be placed over the lesions while they heal.⁵

In severe cases of cold sores, or for people with a compromised immune system who have them, prescribed oral antiviral treatment may be needed.⁸

Preventing chapped lips

Sore, dry or chapped lips are often caused by dehydration after exposure to hot or cold dry air or wind. Sun damage, injury and allergies such as eczema can also affect the lips resulting in dry, flaky, sore skin.⁹

Drinking plenty of fluids to keep hydrated can help as can using a lip balm containing petroleum jelly or beeswax to protect the lips. Covering up lips with a scarf, for example, in cold weather may also help prevent them drying and cracking.⁹ It is important not to lick dry or cracked lips too much because that can just make them worse.⁸

Angular cheilitis

Angular cheilitis is an inflammation of the lips, where lips can appear red and cracked with soreness at the angle of the mouth.¹⁰ The condition differs from cold sores  which appear as groups of small blisters or vesicles, usually on the edge of the lips, that rupture leaving superficial ulcers that crust and heal. And angular cheilitis tends to affect both sides of the mouth whereas cold sores may appear on one part of the lips only, for example.¹¹

Angular cheilitis can be painful and the lips can sometimes bleed.¹² Infection with Candida albicans is the most common cause of angular cheilitis in adults; less frequently the condition is caused by Staphylococcus aureus infection.¹³

However, there are a number of other potential less common causes of angular cheilitis, including: aging; smoking; rapid weight loss; Down syndrome; dermatitis; some cases of nutritional deficiency, and some diseases such as Sjorgen syndrome and inflammatory bowel disease. Repeated exposure to mechanical, chemical and thermal insults can also make the lips more susceptible to inury.¹⁴

Angular cheilitis is more commonly seen in older people, those with ill-fitting dentures, individuals who are immunocompromised or have a vitamin B12 deficiency or iron-deficiency anaemia.¹⁵ People with deep wrinkles in their lip angles and those who lick the lip corners a lot may be more prone to angular cheilitis. Drooling, as a result of increased saliva production, for example, can also be a factor.¹¹

Treating angular cheilitis

Angular cheilitis does not always need treatment as it can resolve itself without intervention. Better general hydration, frequent application of lip balm or thick emollient ointment and possibly topical antiseptics have been found to work to improve the condition.¹⁶ Miconazole cream can help in cases caused by candida infection.^15,17

Coughs and colds in children

These are extremely common in young children, whose symptoms can include a runny or blocked nose, sneezing, sore throat, cough, headache, mild fever, tiredness, aches and pains.

A new, continuous cough could be a sign of Covid infection, so parents should arrange for their child to be tested within five days of symptoms starting. The main symptoms are a high temperature, a new continuous cough and a loss of taste or smell.

However, most coughs and colds are likely to be caused by less harmful viruses. Antibiotics are of no benefit with viruses. Green snot or a noisy chest does not mean that a child has an infection requiring antibiotics either. Noisy chests are also common in young children with viral infections.

You can advise parents to keep their child well hydrated by offering them lots of fluids, recommend paracetamol or ibuprofen if appropriate, as well as saline nose drops or spray which can help ease a blocked nose. If a child is over two years old, vapour rubs can be recommended.

References

1. Clinical Knowledge Summaries. Herpes simplex – oral (https://cks.nice.org.uk/topics/herpes-simplex-oral/have-i-got-the-right-topic; accessed October 2023).
2. British Association of Dermatologists. Herpes simplex patient information leaflet (www.bad.org.uk/pils/herpes-simplex; accessed October 2023).
3. Proprietary Association of Great Britain. OTC Directory online (www.otcdirectory.co.uk/list/search/Cold-Sores,-Warts-and-Other-Skin-Products; accessed October 2023).
4. Pinewood Healthcare. Aciclovir cold sore cream (www.medicines.org.uk/emc/product/9273/smpc; accessed October 2023).
5. NHS Inform. Cold sore (www.nhsinform.scot/illnesses-and-conditions/mouth/cold-sore; accessed October 2023).
6. Primary Care Dermatology Society. Herpes simplex (www.pcds.org.uk/clinical-guidance/herpes-simplex; accessed October 2023).
7. Herpes Viruses Association. Cold sores – questions and answers (https://herpes.org.uk/cold-sores; accessed October 2023).
8. Patient. Cold sores (https://patient.info/childrens-health/viral-skin-infections-leaflet/cold-sores#nav-5; accessed October 2023).
9. NHS.UK. Sore or dry lips (www.nhs.uk/conditions/sore-or-dry-lips; accessed October 2023).
10. Piccinin MA, Zito PM. Anatomy, Head and Neck, Lips. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2023 (www.ncbi.nlm.nih.gov/books/NBK507900; accessed October 2023).
11. Lugović-Mihić L, Pilipović K, Crnarić I, et al. Differential Diagnosis of Cheilitis – How to Classify Cheilitis? Acta Clin Croat 2018;57(2):342–51.
12. Primary Care Dermatology Society. Angular cheilitis (syn. angular stomatitis) (www.pcds.org.uk/clinical-guidance/angular-chelitis; accessed October 2023).
13. Bhutta BS, Hafsi W. Cheilitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 (www.ncbi.nlm.nih.gov/books/NBK470592/#; accessed October 2023).
14. Federico JR, Basehore BM, Zito PM. Angular Chelitis. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2023 (www.ncbi.nlm.nih.gov/books/NBK536929; accessed October 2023).
15. Patient. Candidiasis (https://patient.info/doctor/candidiasis#nav-3; accessed October 2023).
16. DermNet. Angular cheilitis (https://dermnetnz.org/topics/angular-cheilitis; accessed October 2023).
17. British National Formulary. Skin infections (https://bnf.nice.org.uk/treatment-summaries/skin-infections; accessed October 2023).